PATIENT AGREEMENT

Robin E. Weinberger, MSW, LCSW
Psychotherapy / Marital Therapy
Florida License#: SW0000648
22999 NE 191st Street – Suite 703 Aventura, Florida 33180
Telephone: (305) 931-5151

GPATIENT AGREEMENT

I hereby assume responsibility for all charges that may be incurred for counseling/treatment rendered to myself and/or my family member(s).

Because time has been reserved exclusively for me and/or my family member(s), I understand that I am required to provide at least twenty-four (24) hours advance notice if I am unable to keep the scheduled appointment. In the event that I do not provide the required twenty-four (24) hour notice prior to canceling, I understand that I will be charged two hundred dollars ($200), my present hourly professional fee, for the reserved appointment.

I understand the charges may be added to my account for the time for professional services rendered by my therapist (e.g., telephone contacts, consultations with other professionals, preparation of reports or special forms, court documents, etc.).

I am responsible for promptly responding to inquiries from my insurance carrier. If I fail to do so, I will personally be responsible for the charges. If I fail to meet these responsibilities, my account may be turned over to a collection agency of the appropriate court in which case I will be responsible for attorney’s fees, collection costs and court fees. Any amount past due over sixty (60) days will be subject to a 1.5% interest charge per month.

I understand that all conversations with my therapist will be kept confidential and that no information will be released without my written consent. If I am a minor, I am aware that my parents have access to information about my counseling and may authorized release of information on my behalf without my consent. I am aware that certain information may be released without my consent in cases where there is potential, as the result of my behavior, for harm to myself or others, in cases of actual or suspected child abuse or neglect.

We respect your privacy: If you register, request an appointment or submit any other information online, all your information is transmitted securely and is held in strictest confidence, adhering to HIPAA guidelines and protecting your privacy.

NOTICE OF PRIVACY PRACTICES

THIS NOTICE DESCRIBES HOW MEDICAL/PSYCHLKIRIC INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE READ IT CAREFULLY.

Uses and Disclosures: We use health information about you for treatment, to obtain payment for treatment, for administrative purposes, and to evaluate the quality of care that you receive. Continuity of care is part of treatment and your records may be shared with other providers of care to whom you are referred. Information may be shared by telephone, paper mail, electronic mail, fax, or other methods. We may use or disclose identifiable health information about you without your authorization in several situations. However, beyond those situations, we will ask for your written authorization before using or disclosing any identifiable health information about you.

Your rights: In most cases, you have the right to look at or get a copy of health information about you. If you request copies, we will charge you normal photocopy fees. You also have the right to receive a list of certain types of disclosures of your information that we made. If you believe that information in your record is incorrect, you have the right to request that we correct the existing information..

Our legal duty: We are required by law to protect the privacy of your information, provide this notice about our information practices, follow the information practices that are described in this notice, and seek your acknowledgment of receipt of this notice. Before we make a significant change in our policies, we will change our notice and post the new notice in the waiting area.

You can also request a copy of our notice at any time. For more information about our privacy practices, contact the person listed below.

Complaints: If you are concerned that we have violated your privacy rights, or you disagree with a decision. we made about access to your records, you may contact the person listed below. You also may send a written complaint to the U.S. Department of Health and Human Services. The person listed below can provide you with the appropriate address upon request.

If you have any questions or complaints, please contact:

Robin E. Weinberger, LCSW and Associates 2999 NE 191 St., Suite 703 Aventura, Florida 33180 305-931-5151

ROBIN E. WEINBERGER, MSW, LCSW

PATIENT INFORMATION SHEET and PERMANENT LIFETIME SIGNATURE

PATIENT INFORMATION

Patient Name

Address

Phone

** Fees for services are payable at time services are rendered. If unable to keep appointments, kindly give 24 hours advanced notice, otherwise, you will be charged for your visit.**

INSURANCE INFORMATION:

Primary Insurance Carrier:

Secondary Insurance Carrier:

Assignment and Release: The above named provider may use my health care information and may disclose such information to the above named insurance company and their agents for the purpose of obtaining payment for services and determining insurance benefits or the benefits payable for related services. I assign all benefits to be paid directly to Robin Weinberger, MSW, LCSW. I understand that I am financially responsible for all charges whether or not paid by insurance. I authorize the use of my signature on all insurance submissions.

Verification

NOTICE OF PRIVACY PRACTICES

About Robin E. Weinberger, LCSW

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